ABD renewal letter and application - Renewal Application for Aged, Blind and Disabled Programs

Sep 19, 2026

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Renewal instructions and an application form for NJ FamilyCare Aged, Blind, Disabled Programs to continue Medicaid benefits. Beneficiaries must respond by a stated deadline, complete all questions, and sign the application after reviewing Rights and Responsibilities. The packet requires supporting documents to verify eligibility, including income, bank statements, and additional items such as living expense changes, trust statements, life insurance cash surrender value, and health insurance premium changes. The form collects demographic, immigration, race and ethnicity, and income details, plus questions about changes since the last determination.

LanguageEnglish

CategoryLetters

FormatPDF

Pages9

Reading Time3 min

AccessFree to download

Renewal Application for Aged, Blind and Disabled Programs

Renewal instructions

Section 1 Demographic Information

Section 2 Changes since the last eligibility determination

Section 3 Beneficiary’s Income

Renew Your Medicaid Benefits Date: RE: Case \#: Dear NJ FamilyCare Aged, Blind, Disabled Program Beneficiary: It is time to renew! You must respond by or lose your benefits. 1. Complete the application, answer all questions and sign the last page of the application after reading the Rights and Responsibilities section. Be sure to tell us about any changes since your last eligibility determination for you and your spouse. 2. Provide copies of the following documents to verify eligibility. All beneficiaries: • Income • Most recent statement for all bank accounts (including accounts closed since your last determination) If applicable: • Changes in living expenses • Personal Needs Allowance (PNA) account • All Qualified Income Trust/Special Needs Trust bank statements since your last determination • Current cash surrender value of life insurance policy • Plan of liquidation documents (for example: listing agreement, closing settlement) • Changes in Medicare or other health insurance premiums 3. Mail the application and all supporting documents in the envelope provided. You will receive a letter when your Renewal Application is processed. If you have any questions or need help, call at extension . Sincerely, NJ FamilyCare Aged, Blind, Disabled Programs STATE OF NEW JERSEY Department of Human Services Division of Medical Assistance and Health Services RENEWAL APPLICATION INSTRUCTIONS: This form must be completed to continue beneﬁts. The Beneﬁciary is the person already enrolled in the NJ FamilyCare Aged, Blind, Disabled programs. SECTION 1 Demographic Information Beneﬁciary’s Name: PLEASE PRINT Last First Middle Home Address: Street City State Zip Code Current Mailing Address (if diﬀerent from above): Street City State Zip Code Is Beneﬁciary living in a facility? q Yes q No Beneﬁciary’s Phone Number: ( ) - Medicare ID Number: Marital Status: q Single q Married, Date q Divorced, Date q Widowed, Spouse’s Date of Death . q Separated, Date q Child (under age 19) Spouse’s Address (last known): Street City State Zip Code Citizenship Status: q US citizen or US national q Naturalized or derived citizen (born outside of the US) If naturalized or derived citizen, enter USCIS \# and Certiﬁcate \# Certiﬁcate Type: q Naturalization Certiﬁcate q Certiﬁcate of Citizenship If not a citizen, does the Beneﬁciary have an eligible immigration status? Examples of eligible immigration status are: • Child under age 21 or pregnant woman: Lawfully residing in the US • Adult: Lawful Permanent Resident for 5 years OR qualiﬁed non-citizen, such as refugee or asylee FOR OFFICE USE ONLY Date Received Case \# NJ FC-ABD-RA-1222 Renewal Application for Aged, Blind and Disabled Programs SECTION 1-DEMOGRAPHIC INFORMATION-continued q Yes, enter information below: q No Immigration document type Status type (optional) Beneﬁciary’s name as it appears on immigration document USCIS or I-94 number Card or Passport Number SEVIS ID or expiration date (optional) Other (category code or country of origin) Has the Beneﬁciary lived in the US since 1996? q Yes q No Is the Beneﬁciary, or Beneﬁciary’s spouse or parent, a veteran or an active-duty member of the US military? q Yes q No Social Security Number (SSN): – – Your answers to questions about race and ethnicity can help us serve the community better. They will not aﬀect if you qualify for coverage or what services you can receive. Race (Check all that apply) q Prefer not to answer q White q Asian Indian q Korean q Guamanian or Chamorro q American Indian q Chinese q Vietnamese q Native Hawaiian or Alaska Native q Filipino q Other Asian: q Samoan q Black or African American q Japanese q Other Paciﬁc Islander: q Other: Ethnicity (Check all that apply) q Prefer not to answer q Mexican, Mexican American, q Puerto Rican q Another Hispanic, Latino/a, or Spanish

FAQs

What is required to renew NJ FamilyCare Aged, Blind, Disabled benefits?

Complete the application, answer all questions, and sign the last page after reading the Rights and Responsibilities section. Respond by the deadline listed in the notice to avoid losing benefits.

Which documents must be provided to verify eligibility?

Provide copies of income information and the most recent statement for all bank accounts (including accounts closed since the last determination). Additional documents may be required for changes in living expenses, PNA accounts, qualified income trusts/special needs trusts, life insurance cash surrender value, and liquidation plan documents, as applicable.

What does the application collect in Section 1?

Section 1 collects beneficiary demographic details including name, home and mailing addresses, facility living status, phone number, Medicare ID, marital status, spouse information, citizenship/immigration status and document numbers, and race/ethnicity information.

Sep 19, 2026

Upload by Aran